Organization of health services

It is generally the goal of most countries to have their health services organized in such a way to ensure that individuals, families, and communities obtain the maximum benefit from current knowledge and technology available for the promotion, maintenance, and restoration of health. In order to play their part in this process, governments and other agencies are faced with numerous tasks, including the following: (1) They must obtain as much information as is possible on the size, extent, and urgency of their needs; without accurate information, planning can be misdirected. (2) These needs must then be revised against the resources likely to be available in terms of money, manpower, and materials; developing countries may well require external aid to supplement their own resources. (3) Based on their assessments, countries then need to determine realistic objectives and draw up plans. (4) Finally, a process of evaluation needs to be built into the program; the lack of reliable information and accurate assessment can lead to confusion, waste, and inefficiency.

Health services of any nature reflect a number of interrelated characteristics, among which the most obvious, but not necessarily the most important from a national point of view, is the curative function; that is to say, caring for those already ill. Others include special services that deal with particular groups (such as children or pregnant women) and with specific needs such as nutrition or immunization; preventive services, the protection of the health both of individuals and of communities; health education; and, as mentioned above, the collection and analysis of information.

In the curative domain there are various forms of medical practice. They may be thought of generally as forming a pyramidal structure, with three tiers representing increasing degrees of specialization and technical sophistication but catering to diminishing numbers of patients as they are filtered out of the system at a lower level. Only those patients who require special attention either for diagnosis or treatment should reach the second (advisory) or third (specialized treatment) tiers where the cost per item of service becomes increasingly higher. The first level represents primary health care, or first contact care, at which patients have their initial contact with the health-care system.

Primary health care is an integral part of a countrys health maintenance system, of which it forms the largest and most important part. As described in the declaration of Alma-Ata, primary health care should be based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development. Primary health care in the developed countries is usually the province of a medically qualified physician; in the developing countries first contact care is often provided by nonmedically qualified personnel.

The vast majority of patients can be fully dealt with at the primary level. Those who cannot are referred to the second tier (secondary health care, or the referral services) for the opinion of a consultant with specialized knowledge or for X-ray examinations and special tests. Secondary health care often requires the technology offered by a local or regional hospital. Increasingly, however, the radiological and laboratory services provided by hospitals are available directly to the family doctor, thus improving his service to patients and increasing its range. The third tier of health care, employing specialist services, is offered by institutions such as teaching hospitals and units devoted to the care of particular groupswomen, children, patients with mental disorders, and so on. The dramatic differences in the cost of treatment at the various levels is a matter of particular importance in developing countries, where the cost of treatment for patients at the primary health-care level is usually only a small fraction of that at the third level; medical costs at any level in such countries, however, are usually borne by the government.

Ideally, provision of health care at all levels will be available to all patients; such health care may be said to be universal. The well-off, both in relatively wealthy industrialized countries and in the poorer developing world, may be able to get medical attention from sources they prefer and can pay for in the private sector. The vast majority of people in most countries, however, are dependent in various ways upon health services provided by the state, to which they may contribute comparatively little or, in the case of poor countries, nothing at all.

The costs to national economics of providing health care are considerable and have been growing at a rapidly increasing rate, especially in countries such as the United States, Germany, and Sweden; the rise in Britain has been less rapid. This trend has been the cause of major concerns in both developed and developing countries. Some of this concern is based upon the lack of any consistent evidence to show that more spending on health care produces better health. There is a movement in developing countries to replace the type of organization of health-care services that evolved during European colonial times with some less expensive, and for them, more appropriate, health-care system.

In the industrialized world the growing cost of health services has caused both private and public health-care delivery systems to question current policies and to seek more economical methods of achieving their goals. Despite expenditures, health services are not always used effectively by those who need them, and results can vary widely from community to community. In Britain, for example, between 1951 and 1971 the death rate fell by 24 percent in the wealthier sections of the population but by only half that in the most underprivileged sections of society. The achievement of good health is reliant upon more than just the quality of health care. Health entails such factors as good education, safe working conditions, a favourable environment, amenities in the home, well-integrated social services, and reasonable standards of living.

The developing countries differ from one another culturally, socially, and economically, but what they have in common is a low average income per person, with large percentages of their populations living at or below the poverty level. Although most have a small elite class, living mainly in the cities, the largest part of their populations live in rural areas. Urban regions in developing and some developed countries in the mid- and late 20th century have developed pockets of slums, which are growing because of an influx of rural peoples. For lack of even the simplest measures, vast numbers of urban and rural poor die each year of preventable and curable diseases, often associated with poor hygiene and sanitation, impure water supplies, malnutrition, vitamin deficiencies, and chronic preventable infections. The effect of these and other deprivations is reflected by the finding that in the 1980s the life expectancy at birth for men and women was about one-third less in Africa than it was in Europe; similarly, infant mortality in Africa was about eight times greater than in Europe. The extension of primary health-care services is therefore a high priority in the developing countries.

The developing countries themselves, lacking the proper resources, have often been unable to generate or implement the plans necessary to provide required services at the village or urban poor level. It has, however, become clear that the system of health care that is appropriate for one country is often unsuitable for another. Research has established that effective health care is related to the special circumstances of the individual country, its people, culture, ideology, and economic and natural resources.

The rising costs of providing health care have influenced a trend, especially among the developing nations, to promote services that employ less highly trained primary health-care personnel who can be distributed more widely in order to reach the largest possible proportion of the community. The principal medical problems to be dealt with in the developing world include undernutrition, infection, gastrointestinal disorders, and respiratory complaints, which themselves may be the result of poverty, ignorance, and poor hygiene. For the most part, these are easy to identify and to treat. Furthermore, preventive measures are usually simple and cheap. Neither treatment nor prevention requires extensive professional training: in most cases they can be dealt with adequately by the primary health worker, a term that includes all nonprofessional health personnel.

Those concerned with providing health care in the developed countries face a different set of problems. The diseases so prevalent in the Third World have, for the most part, been eliminated or are readily treatable. Many of the adverse environmental conditions and public health hazards have been conquered. Social services of varying degrees of adequacy have been provided. Public funds can be called upon to support the cost of medical care, and there are a variety of private insurance plans available to the consumer. Nevertheless, the funds that a government can devote to health care are limited and the cost of modern medicine continues to increase, thus putting adequate medical services beyond the reach of many. Adding to the expense of modern medical practices is the increasing demand for greater funding of health education and preventive measures specifically directed toward the poor.

In many parts of the world, particularly in developing countries, people get their primary health care, or first-contact care, where available at all, from nonmedically qualified personnel; these cadres of medical auxiliaries are being trained in increasing numbers to meet overwhelming needs among rapidly growing populations. Even among the comparatively wealthy countries of the world, containing in all a much smaller percentage of the worlds population, escalation in the costs of health services and in the cost of training a physician has precipitated some movement toward reappraisal of the role of the medical doctor in the delivery of first-contact care.

In advanced industrial countries, however, it is usually a trained physician who is called upon to provide the first-contact care. The patient seeking first-contact care can go either to a general practitioner or turn directly to a specialist. Which is the wisest choice has become a subject of some controversy. The general practitioner, however, is becoming rather rare in some developed countries. In countries where he does still exist, he is being increasingly observed as an obsolescent figure, because medicine covers an immense, rapidly changing, and complex field of which no physician can possibly master more than a small fraction. The very concept of the general practitioner, it is thus argued, may be absurd.

The obvious alternative to general practice is the direct access of a patient to a specialist. If a patient has problems with vision, he goes to an eye specialist, and if he has a pain in his chest (which he fears is due to his heart), he goes to a heart specialist. One objection to this plan is that the patient often cannot know which organ is responsible for his symptoms, and the most careful physician, after doing many investigations, may remain uncertain as to the cause. Breathlessnessa common symptommay be due to heart disease, to lung disease, to anemia, or to emotional upset. Another common symptom is general malaisefeeling run-down or always tired; others are headache, chronic low backache, rheumatism, abdominal discomfort, poor appetite, and constipation. Some patients may also be overtly anxious or depressed. Among the most subtle medical skills is the ability to assess people with such symptoms and to distinguish between symptoms that are caused predominantly by emotional upset and those that are predominantly of bodily origin. A specialist may be capable of such a general assessment, but, often, with emphasis on his own subject, he fails at this point. The generalist with his broader training is often the better choice for a first diagnosis, with referral to a specialist as the next option.

It is often felt that there are also practical advantages for the patient in having his own doctor, who knows about his background, who has seen him through various illnesses, and who has often looked after his family as well. This personal physician, often a generalist, is in the best position to decide when the patient should be referred to a consultant.

The advantages of general practice and specialization are combined when the physician of first contact is a pediatrician. Although he sees only children and thus acquires a special knowledge of childhood maladies, he remains a generalist who looks at the whole patient. Another combination of general practice and specialization is represented by group practice, the members of which partially or fully specialize. One or more may be general practitioners, and one may be a surgeon, a second an obstetrician, a third a pediatrician, and a fourth an internist. In isolated communities group practice may be a satisfactory compromise, but in urban regions, where nearly everyone can be sent quickly to a hospital, the specialist surgeon working in a fully equipped hospital can usually provide better treatment than a general practitioner surgeon in a small clinic hospital.

Before 1948, general practitioners in Britain settled where they could make a living. Patients fell into two main groups: weekly wage earners, who were compulsorily insured, were on a doctors panel and were given free medical attention (for which the doctor was paid quarterly by the government); most of the remainder paid the doctor a fee for service at the time of the illness. In 1948 the National Health Service began operation. Under its provisions, everyone is entitled to free medical attention with a general practitioner with whom he is registered. Though general practitioners in the National Health Service are not debarred from also having private patients, these must be people who are not registered with them under the National Health Service. Any physician is free to work as a general practitioner entirely independent of the National Health Service, though there are few who do so. Almost the entire population is registered with a National Health Service general practitioner, and the vast majority automatically sees this physician, or one of his partners, when they require medical attention. A few people, mostly wealthy, while registered with a National Health Service general practitioner, regularly see another physician privately; and a few may occasionally seek a private consultation because they are dissatisfied with their National Health Service physician.

A general practitioner under the National Health Service remains an independent contractor, paid by a capitation fee; that is, according to the number of people registered with him. He may work entirely from his own office, and he provides and pays his own receptionist, secretary, and other ancillary staff. Most general practitioners have one or more partners and work more and more in premises built for the purpose. Some of these structures are erected by the physicians themselves, but many are provided by the local authority, the physicians paying rent for using them. Health centres, in which groups of general practitioners work have become common.

In Britain only a small minority of general practitioners can admit patients to a hospital and look after them personally. Most of this minority are in country districts, where, before the days of the National Health Service, there were cottage hospitals run by general practitioners; many of these hospitals continued to function in a similar manner. All general practitioners use such hospital facilities as X-ray departments and laboratories, and many general practitioners work in hospitals in emergency rooms (casualty departments) or as clinical assistants to consultants, or specialists.

General practitioners are spread more evenly over the country than formerly, when there were many in the richer areas and few in the industrial towns. The maximum allowed list of National Health Service patients per doctor is 3,500; the average is about 2,500. Patients have free choice of the physician with whom they register, with the proviso that they cannot be accepted by one who already has a full list and that a physician can refuse to accept them (though such refusals are rare). In remote rural places there may be only one physician within a reasonable distance.

Until the mid-20th century it was not unusual for the doctor in Britain to visit patients in their own homes. A general practitioner might make 15 or 20 such house calls in a day, as well as seeing patients in his office or surgery, often in the evenings. This enabled him to become a family doctor in fact as well as in name. In modern practice, however, a home visit is quite exceptional and is paid only to the severely disabled or seriously ill when other recourses are ruled out. All patients are normally required to go to the doctor.

It has also become unusual for a personal doctor to be available during weekends or holidays. His place may be taken by one of his partners in a group practice, a provision that is reasonably satisfactory. General practitioners, however, may now use one of several commercial deputizing services that employs young doctors to be on call. Although some of these young doctors may be well experienced, patients do not generally appreciate this kind of arrangement.

Whereas in Britain the doctor of first contact is regularly a general practitioner, in the United States the nature of first-contact care is less consistent. General practice in the United States has been in a state of decline in the second half of the 20th century, especially in metropolitan areas. The general practitioner, however, is being replaced to some degree by the growing field of family practice. In 1969 family practice was recognized as a medical specialty after the American Academy of General Practice (now the American Academy of Family Physicians) and the American Medical Association created the American Board of General (now Family) Practice. Since that time the field has become one of the larger medical specialties in the United States. The family physicians were the first group of medical specialists in the United States for whom recertification was required.

There is no national health service, as such, in the United States. Most physicians in the country have traditionally been in some form of private practice, whether seeing patients in their own offices, clinics, medical centres, or another type of facility and regardless of the patients income. Doctors are usually compensated by such state and federally supported agencies as Medicaid (for treating the poor) and Medicare (for treating the elderly); not all doctors, however, accept poor patients. There are also some state-supported clinics and hospitals where the poor and elderly may receive free or low-cost treatment, and some doctors devote a small percentage of their time to treatment of the indigent. Veterans may receive free treatment at Veterans Administration hospitals, and the federal government through its Indian Health Service provides medical services to American Indians and Alaskan natives, sometimes using trained auxiliaries for first-contact care.

In the rural United States first-contact care is likely to come from a generalist. The middle- and upper-income groups living in urban areas, however, have access to a larger number of primary medical care options. Children are often taken to pediatricians, who may oversee the childs health needs until adulthood. Adults frequently make their initial contact with an internist, whose field is mainly that of medical (as opposed to surgical) illnesses; the internist often becomes the family physician. Other adults choose to go directly to physicians with narrower specialties, including dermatologists, allergists, gynecologists, orthopedists, and ophthalmologists.

Patients in the United States may also choose to be treated by doctors of osteopathy. These doctors are fully qualified, but they make up only a small percentage of the countrys physicians. They may also branch off into specialties, but general practice is much more common in their group than among M.D.s.

It used to be more common in the United States for physicians providing primary care to work independently, providing their own equipment and paying their own ancillary staff. In smaller cities they mostly had full hospital privileges, but in larger cities these privileges were more likely to be restricted. Physicians, often sharing the same specialties, are increasingly entering into group associations, where the expenses of office space, staff, and equipment may be shared; such associations may work out of suites of offices, clinics, or medical centres. The increasing competition and risks of private practice have caused many physicians to join Health Maintenance Organizations (HMOs), which provide comprehensive medical care and hospital care on a prepaid basis. The cost savings to patients are considerable, but they must use only the HMO doctors and facilities. HMOs stress preventive medicine and out-patient treatment as opposed to hospitalization as a means of reducing costs, a policy that has caused an increased number of empty hospital beds in the United States.

While the number of doctors per 100,000 population in the United States has been steadily increasing, there has been a trend among physicians toward the use of trained medical personnel to handle some of the basic services normally performed by the doctor. So-called physician extender services are commonly divided into nurse practitioners and physicians assistants, both of whom provide similar ancillary services for the general practitioner or specialist. Such personnel do not replace the doctor. Almost all American physicians have systems for taking each others calls when they become unavailable. House calls in the United States, as in Britain, have become exceedingly rare.

In Russia general practitioners are prevalent in the thinly populated rural areas. Pediatricians deal with children up to about age 15. Internists look after the medical ills of adults, and occupational physicians deal with the workers, sharing care with internists.

Teams of physicians with experience in varying specialties work from polyclinics or outpatient units, where many types of diseases are treated. Small towns usually have one polyclinic to serve all purposes. Large cities commonly have separate polyclinics for children and adults, as well as clinics with specializations such as womens health care, mental illnesses, and sexually transmitted diseases. Polyclinics usually have X-ray apparatus and facilities for examination of tissue specimens, facilities associated with the departments of the district hospital. Beginning in the late 1970s was a trend toward the development of more large, multipurpose treatment centres, first-aid hospitals, and specialized medicine and health care centres.

Home visits have traditionally been common, and much of the physicians time is spent in performing routine checkups for preventive purposes. Some patients in sparsely populated rural areas may be seen first by feldshers (auxiliary health workers), nurses, or midwives who work under the supervision of a polyclinic or hospital physician. The feldsher was once a lower-grade physician in the army or peasant communities, but feldshers are now regarded as paramedical workers.

In Japan, with less rigid legal restriction of the sale of pharmaceuticals than in the West, there was formerly a strong tradition of self-medication and self-treatment. This was modified in 1961 by the institution of health insurance programs that covered a large proportion of the population; there was then a great increase in visits to the outpatient clinics of hospitals and to private clinics and individual physicians.

When Japan shifted from traditional Chinese medicine with the adoption of Western medical practices in the 1870s, Germany became the chief model. As a result of German influence and of their own traditions, Japanese physicians tended to prefer professorial status and scholarly research opportunities at the universities or positions in the national or prefectural hospitals to private practice. There were some pioneering physicians, however, who brought medical care to the ordinary people.

Physicians in Japan have tended to cluster in the urban areas. The Medical Service Law of 1963 was amended to empower the Ministry of Health and Welfare to control the planning and distribution of future public and nonprofit medical facilities, partly to redress the urban-rural imbalance. Meanwhile, mobile services were expanded.

The influx of patients into hospitals and private clinics after the passage of the national health insurance acts of 1961 had, as one effect, a severe reduction in the amount of time available for any one patient. Perhaps in reaction to this situation, there has been a modest resurgence in the popularity of traditional Chinese medicine, with its leisurely interview, its dependence on herbal and other natural medicines, and its other traditional diagnostic and therapeutic practices. The rapid aging of the Japanese population as a result of the sharply decreasing death rate and birth rate has created an urgent need for expanded health care services for the elderly. There has also been an increasing need for centres to treat health problems resulting from environmental causes.

On the continent of Europe there are great differences both within single countries and between countries in the kinds of first-contact medical care. General practice, while declining in Europe as elsewhere, is still rather common even in some large cities, as well as in remote country areas.

In The Netherlands, departments of general practice are administered by general practitioners in all the medical schoolsan exceptional state of affairsand general practice flourishes. In the larger cities of Denmark, general practice on an individual basis is usual and popular, because the physician works only during office hours. In addition, there is a duty doctor service for nights and weekends. In the cities of Sweden, primary care is given by specialists. In the remote regions of northern Sweden, district doctors act as general practitioners to patients spread over huge areas; the district doctors delegate much of their home visiting to nurses.

In France there are still general practitioners, but their number is declining. Many medical practitioners advertise themselves directly to the public as specialists in internal medicine, ophthalmologists, gynecologists, and other kinds of specialists. Even when patients have a general practitioner, they may still go directly to a specialist. Attempts to stem the decline in general practice are being made by the development of group practice and of small rural hospitals equipped to deal with less serious illnesses, where general practitioners can look after their patients.

Although Israel has a high ratio of physicians to population, there is a shortage of general practitioners, and only in rural areas is general practice common. In the towns many people go directly to pediatricians, gynecologists, and other specialists, but there has been a reaction against this direct access to the specialist. More general practitioners have been trained, and the Israel Medical Association has recommended that no patient should be referred to a specialist except by the family physician or on instructions given by the family nurse. At Tel Aviv University there is a department of family medicine. In some newly developing areas, where the doctor shortage is greatest, there are medical centres at which all patients are initially interviewed by a nurse. The nurse may deal with many minor ailments, thus freeing the physician to treat the more seriously ill.

Nearly half the medical doctors in Australia are general practitionersa far higher proportion than in most other advanced countriesthough, as elsewhere, their numbers are declining. They tend to do far more for their patients than in Britain, many performing such operations as removal of the appendix, gallbladder, or uterus, operations that elsewhere would be carried out by a specialist surgeon. Group practices are common.

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